Healthcare Provider Details

I. General information

NPI: 1477064848
Provider Name (Legal Business Name): KATIE HALTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8253
  • Fax: 616-940-5357
Mailing address:
  • Phone: 616-965-8253
  • Fax: 616-940-5357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008462
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: